COVID Investigator Praises Community Health Workers: “Huge Innovation”

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Mark Masselli ( 00:05 ):
Covid has been called a lot of things, but a group of prominent investigators have now labeled it a war,
as big, a global fight as World War II. What else can we call a pandemic that has caused over one million
deaths in the United States and as many as 20 million worldwide? But what are the lessons from the war
and are we following them?

Margaret Flinter ( 00:27 ):
Here to answer those questions is Philip Zelikow, with the Covid Crisis Group. He's the lead author of
their book, Lessons from the Covid War, published by Public Affairs.

Philip Zelikow ( 00:37 ):
We point out in the report that community health workers can play this extraordinary role, but currently
are limited by design in where we can actually set up the federally qualified health FQHC system. And
we say that right now by design, community health workers are only available to about 9% of the
American population. That's your 30 million people. But where we had them, they were really effective.
And that's like a huge innovation that should punch out to us as a lesson from this war.

Margaret Flinter ( 01:17 ):
And this is Conversations on Healthcare.

Mark Masselli ( 01:27 ):
Well, Professor Zelikow, welcome to Conversations on Healthcare.

Philip Zelikow ( 01:32 ):
Glad to be with you.

Mark Masselli ( 01:33 ):
That's great. We recognize many of the book's co - authors from their interviews with us during the past
three years, and we preface our first question by noting that you have served in Republican
administrations, and that's why perhaps the most controversial part of the book is where you state that
then President Trump abdicated his duty of national leadership. The book refers to him as a quote,
comorbidity, in this crisis. Yet the Washington Post book review says the book goes too far to minimize
Trump's role. How do you react to that charge?

Philip Zelikow ( 02:08 ):
I think people just can read the book and judge for themselves. You just have to break it down and
analyze it. It's not President Trump's fault that our leading experts called the pandemic a low risk, quote,
unquote, all through February of 2020. That wasn't President Trump's call, although he also wanted to
downplay and minimize the virus. It wasn't President Trump's fault that we had no ability to partner
with private industry to mass produce tests. It wasn't President Trump's fault that we had no plan to use
the tests that we did produce. It wasn't his fault that we didn't have biomedical surveillance in order to
track cases so that authorities were flying blind and responding to the virus. I could go on. No one
reading this report will think that President Trump should be anywhere near government. So let's be
clear about this.

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( 03:11 ):
And by the way, I've worked for both Democratic and Republican administrations. I've held positions at
the federal level in five different administrations. But the mistake is that each side then develops its
satisfying narratives of blame. So on the Republican side, it's let's blame China or let's blame Tony Fauci.
On the Democratic side, let's lay it off on Trump, as if we had had a proper Democratic president, we
would've managed this pretty well. And that's fundamentally false. And the danger in those blame
narratives, as satisfying as they are psychologically, is that they miss the fact that just structurally and in
so many ways, the American system was not prepared to cope with this pandemic. It wouldn't have
been prepared to cope with it if a democratic president had been in power. Did Trump make things
worse? Yes. Hence, the phrase comorbidity.
( 04:14 ):
Comorbidity is a condition that increases your chance of... It's a preexisting condition that increases your
chance of death or serious illness. And Trump was certainly that. But if we then think that Trump was
really the source of the problem, that's a mistake. And actually if we think that toxic politics was the
source of the problem, that's also actually a mistake. The report explains fairly carefully that in fact, toxic
politics was often the result of policy failure, not the other way around. That as the pandemic unfolded
in the spring of 2020, it was obvious that a lot of authorities were flailing around to try to come up with
an answer, and that they didn't know what to do after the initial set of lockdowns, which is true. And
into that void, all the toxic politics could then flow in.
( 05:14 ):
But there was actually quite a hunger at the outset among a lot of people to listen to and accept well
coordinated guidance that seemed reasonably well grounded. I think actually in many ways, that
willingness to look for guidance and hunger for guidance persists well into 2020. The school closures, for
example, by late 2020 and on into 2021, were more the product of the failure of adequate practical
guidance. And then that created the paralysis that allowed schools to remain closed while affluent
countries all around the world were reopening theirs.

Margaret Flinter ( 05:57 ):
Well, I found it interesting that before Covid, the Johns Hopkins Center for Health Security rate of the US
as the number one most prepared country for a pandemic, which on all the levels that you've just
described, no one was saying that after the pandemic got going. We didn't have the kind of
preparedness other countries did. But we also have seen reported that the National Security Council did
have a playbook on fighting pandemics. And I don't know what our listeners know about playbooks, but
they're usually extremely detailed and designed as the go - to document to get started right away when
something hits. What insights can you shed on the fact that it appears that the Trump administration
and the country kind of ignored the playbook that had been developed to fight pandemics?

Philip Zelikow ( 06:45 ):
Well, I'm so glad you mentioned that because we actually read the playbook and the report discusses
the playbook in some detail. There was no playbook. There is a document called a Playbook. If you read
that document, what it really is, it's more of a diagnostic manual about how to classify an outbreak in
order to invoke certain authorities. If you're looking for something that diagrams exactly what we will do
in the crisis and what all the different agencies are supposed to do, if you're looking for something that
provides operational guidance, the Playbook, as we say in the report was, quote, a blank page. It didn't

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actually draw out any place. There's, in fact, later on there was a quote, unquote, Crisis Action Plan,
developed in the spring of 2020.
( 07:43 ):
But actually, if you sit down and read the Crisis Action Plan, it doesn't actually detail any of the actions
that are supposed to be done. Once again, it's basically a process guide for how to invoke certain
authorities and trying to sort out the alphabet soup of possible agencies to respond. The fundamental
problem all through this is a life of preparedness. And in fact, when you look at these documents, they
underscore the lack of preparedness. They weren't ignored. The veterans in government who were
operating this machinery didn't kind of blow off the playbook that actually they themselves had helped
prepare. It's just that the playbook offered really nothing useful to say about how to handle this national
emergency.

Mark Masselli ( 08:33 ):
I want to also note that you had a bipartisan approach. You also take President Biden and his
administration to task. You highlight their missteps with the Covid treatment, paxlovid, and with testing
school closing, you mentioned. Take us through your observations about the Biden administration.

Philip Zelikow ( 08:50 ):
Well, to be fair to the Biden administration, they basically rebuilt the federal crisis management system
that had collapsed during the Trump administration. Federal crisis management essentially collapsed,
we argue, in April and May of 2020. So the Biden administration rebuilt that mechanism pretty much
along the lines of the Berks machinery that was in place by March, 2020 in which the Trump
administration then effectively discarded. They put a man named Jeff [inaudible 00:09:26] in charge of
that. And that machinery did a good job of kind of tactical crisis management, putting out the daily fires,
organizing daily updates. And that was helpful. But it didn't really provide powerful strategic insight for
broad policies either globally or nationally that would be markedly different. It didn't redress any of the
issues of biomedical surveillance and genomic surveillance very well. It actually let the mass production
of testing programs substantially expire, which then had to be frantically rebuilt later in the year.
( 10:06 ):
Operation Warp Speed had already failed to carry out a manufacturing and distribution program for
drugs for therapeutics like paxlovid. So for example, in early 2021, when the Biden administration had to
decide whether to make advanced market commitments, like Warp Speed did on vaccines, advanced
market commitments to buy a lot of paxlovid, the Biden administration passed on that. So the result
then when paxlovid was shown to be 90% effective in October, November of 2021, the Biden
administration had placed no orders for it. So it started frantically placing orders for it, but then the
Omicron wave hit and we basically had almost no courses of paxlovid bit available to treat patients
during the Omicron wave, which probably cost a lot of lives.
( 10:59 ):
By the way, the Biden administration, like the Trump administration, never actually gave doctors a lot of
practical guidance about how to use some of the treatments that were being approved to treat Covid,
like the monoclonal antibodies or paxlovid, with the result being that actually to this day, most patients
who get Covid are not being properly treated with available medications.
( 11:22 ):

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But the main point that the report draws out is that the fundamental trajectory of how to respond to
the Covid war was pretty well set during the Trump administration. The Biden administration, if it can be
faulted, is basically at fault because it didn't really change that trajectory, fundamentally. It did do some
good thing, it was slow on fixing the school's problem, but it did get to that very well in late 2021 and
the winter of '21, '22 combined with a well financed testing program and the like. So there are a number
of bright spots in the Biden administration's performance, including on programs to encourage vaccine
uptake. But the basic trajectory of the crisis response had already been set and the Biden administration
didn't change that.

Margaret Flinter ( 12:16 ):
Philip, I'd like to just go back and maybe I missed this, but I think it's such an important point. We've
always been glad to have Dr. Fauci as a guest on the show. He's been on a few times and he recently
said to the New York Times that the country actually could have had the vaccines out there much
quicker than it did, and that the phase two safety trial was done by early July, 2020.
( 12:39 ):
Now, those vaccines, I think we were among the first kinds of organizations to receive them. They
arrived on our doorsteps, I think around December 23rd or so. What does your investigation say on this
front about that delay when that was such a critical element to get out there as soon as possible?

Philip Zelikow ( 12:59 ):
Well, actually, we do have a lot to say about the medical countermeasure story, and I think we have the
best published account available right now, of both the origins of Operation Warp Speed and how it
unfolded in both strengths and weaknesses.
( 13:18 ):
Let's see. A few points. First, you couldn't hurry the FDA approvals of the vaccines much more than they
were hurried. The FDA was actually pressured to hurry their approvals by Trump administration officials.
But because they'd already been pretty spectacularly burned on some controversial drug approvals.
Actually, most recently convalescent plasma. Stephen Hahn and Peter Marks at FDA were kind of
reluctant to do anything that would rush the vaccine approvals until they had the trial data, which they
didn't really get until about October of 2020. This is point one.
( 14:00 ):
Point two. Operation Warp Speed was not mainly a program though that accelerated the R&D efforts.
We were lucky that there had already been a lot of investment, including government investment on
Coronaviruses before the pandemic broke. We were lucky that the mRNA platforms turned out to be so
effective. But the Pfizer, for example, refused to participate in the R&D part of Operation Warp Speed,
but developed its vaccine on the same timetable as Moderna.
( 14:34 ):
Where Operation Warp Speed really scored, and what accounted for a lot of this delay is manufacturing
at scale and distribution. And Warp Speed did a very good job on manufacturing, including by the way
manufacturing of the Pfizer vaccine. It did a very good job in planning for distribution of the vaccine
through the American Drugstore system, a plan that actually was aided by a really gifted employee at
CDC. So those were success stories. The Operation Warp Speed never really developed a campaign to
persuade people to take the vaccines to accompany the rollout. And that was one of the places where
they let down. And the bi - America approach in Warp Speed would later actually backfire both globally

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and backfired for American businesses in the vaccine supply chain. But Dr. Fauci's point tends to focus
too much on the R&D side of it and not enough on the fundamental challenges, as even once you've got
the vaccine approved, being able to rapidly manufacture at scale in order to get billions of doses out.

Mark Masselli ( 15:53 ):
I'm thinking about the crisis response and really thinking about it through the political lens of the
challenges that our leaders faced. I'm thinking right now you have Robert F. Kennedy Jr.'s running in the
Democratic primary for president. He's probably about 19%. He's a hardcore anti - vaxxer, alleges the
government cover up. What do you say to him, and those that apparently support his perspective? And
what type of influence did that large group of Americans have on both administrations as they tried to
sort of formulate their policy of how do you respond in this war crisis?

Philip Zelikow ( 16:35 ):
Yeah. Well, first the good news is that over the years, people who are experts in crisis communication
have developed a really good set of approaches for how to do effective crisis communication. The bad
news is that during the Covid War, our leaders ignored all of these principles. So the quality of crisis
communication and best practices in crisis communication were pretty much discarded and people
improvised. And actually, the prominence of Dr. Fauci is revealing symptom of the problem, in a way. Dr.
Fauci should not be the lead crisis communicator, ordinarily. He doesn't lead a policy agency. People
turned to him because he seemed like he was the only adult voice in the room there for a while. In my
day job as an academic, I usually work as a historian. And if we step back and look at the history of
American attitudes towards vaccination, towards public health, you'll see actually that Americans have
always been suspicious and distrustful of public health authorities.
( 17:50 ):
There's always been a lot of unease about vaccination campaigns, even going back to vaccination against
small box that sometimes vaccination campaigns were almost done at force, forcibly, in the late 19th
century and early 20th century. Before the Covid War, actually, a lot of the criticisms of over weaning
public health authorities came from academics who were writing from a progressive or leftist attitude
because they thought that these authorities were often used against marginal parts of society, people in
slums or tenements and so forth. So there's always been some controversy and unease about this in
American society.
( 18:38 ):
So rather than then take the stance that, well, you can't get people to take vaccines, you just have to
then make your arguments and you have to work really, really hard at making them. And what we found
in the crisis, and this is one of the lessons that shouldn't be forgotten, one of the lessons we're trying
not to lose is that when we made proper efforts to encourage people to use vaccines, those efforts
actually tended to work.
( 19:07 ):
These efforts don't consist of getting some authority figure to cut a public service announcement in
mass media. The efforts that tended to work was where people would just take the time to really
explain candidly what works and doesn't work about vaccines to people who are trusted intermediaries
in local communities. So for instance, a pilot program on this worked with the American Farm Bureau
Federation in order to find trusted intermediaries to reach out to people in rural communities around
America. Another initiative worked to reach out to urban communities, for instance, through black
churches, leaders there to deliver personal messages from intermediaries who were trusted in those

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communities. And those sorts of approaches actually worked. And ultimately, vaccine uptake in America
actually over time has been very high, at least for the first vaccine, approaching 90% eventually.
( 20:10 ):
So in other words, I'm not basically dismissing the distrust and skepticism that people like Robert F.
Kennedy Jr. Represent rather than dismiss it or look down on that, take that seriously as kind of a
constant problem in our society or a constant unease. And then if you've got good scientific evidence
and can explain it, do that and take people's concerns seriously and address them. I think a lot of your
listeners who work in the medical care field have a lot of experience in how to listen to patient concerns,
take them seriously and address them. And they probably find that it helps to do that in a person to
person way.

Margaret Flinter ( 20:55 ):
You're absolutely right about that, and that certainly has been a big focus of the work of community -
based healthcare organizations in particular. But Philip, you've said that America doesn't really have a
national public health agency, but I have a feeling a lot of people would say CDC. Isn't that our national
public health agency?

Philip Zelikow ( 21:15 ):
And by the way, including some people at CDC would say that.

Margaret Flinter ( 21:20 ):
But I guess the question is given that one of the elements of a national public health agency is that they
would have the capability around the country to make these trade - offs and decision making around
education and economic harm and public health issues, is it your belief, would you be making a
recommendation that Congress should create such a national agency to supplement or to organize the
hundreds of local and state health departments and territories that we have now?

Philip Zelikow ( 21:49 ):
We don't actually call for creating some giant new federal agency to take overall public health functions.
We actually see a lot of strengths in aspects of the federal system. But it's really important to be clear
about what we had here in this pandemic. And one of the things that distinguished us from almost all
other affluent countries. We had a system designed fundamentally in the late 19th century, structurally,
an 1890s era system confronting a 21st century pandemic.
( 22:23 ):
So what does that mean? It means that virtually all operational and executive authority is at the state
and local and tribal and territorial level scattered among hundreds of different entities, which are not at
all alike. Those entities, in turn, are chronically underfunded, understaffed. They themselves are entirely
detached from the healthcare system, which is where we put most of our money and our energy. And
both of those, public health and the healthcare system, which are detached from each other, are also
detached from the biopharma industrial complex that then has to manufacture your award - winning
weapons in these crises, with no one having a real system of national executive authority, even at the
level of guidance, effective practical guidance.
( 23:15 ):

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So CDC actually had this image of itself as the national public health agency, but has no executive
authority or operational capability around the country. And when confronted with a national
emergency, has boutique disease detectives. And so then the issue first of all is to say, given our federal
system, what should be the roles and missions for the different entities? And we think CDC has a role to
play, but probably not as the executive in charge of mapping the overall response. We call for a national
health security enterprise concept that probably has some kind of executive guidance that writes sheet
music for this complicated orchestra we've got. Public health, healthcare, biopharma, at least the
different sections should do their roles in missions, but against the common melody. Someone's got to
write the sheet music, the orchestra needs a conductor. That probably needs to be in Washington.
( 24:26 ):
The Congress has of course, come up with the idea of creating a new White House czar, which by the
way, the Biden White House didn't want. But now it has. That could actually compound the confusion
because it doesn't have operational authority or budget lines. We actually suggested putting some of
this capability in the HHS department with a new under secretary that could coordinate the baronies
between CDC, FDA and IH, the Assistant Secretary for Health, Public Health Service, Office of Global
Affairs, which it itself is... And then there's the stuff in the Department of Homeland Security and DOD.
( 25:10 ):
So we saw the need to do a better job of organizing for a national emergency. But a lot of the authorities
that one could wish to have are actually already there in places like the Center for Medicare and
Medicaid Services, which right now has a lot of authorities to tell hospitals about the capabilities they
need to have. There are things we could do in the existing system with existing technology to better
coordinate the often outstanding electronic health records and data we have in the healthcare system
with the lamentable situation of the data and the public health system.

Mark Masselli ( 25:49 ):
Tell me this. How scared should we be because we had SARS, MIRS, Zika, coronavirus. It sounds like the
plan is maybe in the distant future. I'm not sure Americans understand this could happen at any time.
The one thing that we heard from Dr. Fauci in February of 2020 when we had him on, is coronavirus
mutates. This could mutate quickly, but there are other potential problems. It doesn't seem like we are
ready now. And if you were talking about a war, the military's well - funded. Not that they're perfect, but
they're planning every day. It's not only that we understand the organizational chart of what should
happen, but they have to practice because it's a very complicated system. And it sounds like listening to
you that we are nowhere in terms of the next pandemic, which could, when we were all sitting here
January, 2020, life was fine. Two months later, life was not fine. So tell me what keeps you up at night?

Philip Zelikow ( 27:01 ):
Well, I'm afraid our group's conclusion is that fundamentally, structurally, we're no more prepared for a
more virulent pandemic today than we were in early 2020. Nothing really. The government itself has not
done its own internal after action report to try to figure out how to make all this better. That's partly
why we wrote our report. It's not like the government did this work, knows what to do, but hasn't done
it. The government didn't do this work, doesn't really know what to do and hasn't done it.
( 27:34 ):
So we've written this report to make some suggestions about what can be done. And we think actually
anyone reading the report will see that there is a ton of low hanging fruit all over the place that can be
done without grand new congressional legislation. So that's actually encouraging, that's empowering.

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You don't need a miraculous politics where everyone now comes together in order to make this a lot
better. And this all just offers a lot of insights for how to get ready for any major emergency that we
might encounter in the future. We called out Connecticut actually as a good state.
( 28:12 ):
We talked actually to Albert Ko and Indra Nooyi and folks who helped lead the task force there. The
other thing, we hit hard, the community health worker movement, which I think is you're alluding to,
which has not gotten enough attention except for a young piece in The Atlantic that was helpful.
( 28:41 ):
And we point out in the report that community health workers can play this extraordinary role, but
currently are limited by design in where we can actually set up the federally qualified health FQHC
system. And we say that right now, by design, community health workers are only available to about 9%
of the American population. That's your 30 million people. But where we had them, they were really
effective. And that's like a huge innovation that should punch out to us as a lesson from this war.
( 29:21 ):
But to come back to your original question, how scared should we be? There is some new research now
in which experts try to estimate the likelihood of another Covid scale pandemic or worse. And they
actually see a pretty large chance of this just in the next 10 years. So they're very worried. There was the
fact that Covid - 19 had a lethality that was about one fourth of what the influenza was in 1918, 1919, or
about one 20th of the lethality of SARS - 1. This is a kind of biological luck. There's nothing that's
predestined that anything that's contagious can't be virulent. So we're just kind of waiting and hoping
and in an environment where for lots of reasons, including genetic engineering advances encroachments
on habitat, the dangers of some sort of new biological outbreak are greater now than perhaps at any
other time in human history.

Margaret Flinter ( 30:31 ):
Well, Professor Zelikow, thank you for being with us. Thank you for sounding that clarion call for
preparedness and better preparedness for what might be ahead of us. And thanks to our audience.
There's more online about Conversations on Healthcare, including a way to sign up for updates. Our
address is chcradio.com. Professor Zelikow, thank you to you and to the members of your group that
produced the report. We appreciate the contribution that you've made.

Philip Zelikow ( 30:55 ):
You're most welcome.

Mark Masselli ( 30:58 ):
And what an important public service.

Philip Zelikow ( 30:59 ):
Thank you.

Mark Masselli ( 31:00 ):
Thank you.

Margaret Flinter ( 31:06 ):

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